A 74-year-old man comes to the office due to difficulty swallowing food. The symptoms began 4 months ago when the patient was eating steak and felt like a bite got stuck in the middle of his chest, which resolved after drinking a glass of water. Since then, he has had several similar episodes when eating bread or meat and has modified his diet to soft foods. He has no difficulty drinking liquids and has had no chest or abdominal pain, vomiting, melena, or weight loss. The patient has occasional nighttime heartburn, especially after eating spicy food, and takes antacids as needed. His other medical conditions include hypertension, for which he takes lisinopril. He does not use tobacco, alcohol, or illicit drugs. Family history is unremarkable. Vital signs are within normal limits. Physical examination shows normal dentition and oropharyngeal mucosa. Tonsils are normal. The lungs are clear on auscultation, and heart sounds are normal. The abdomen is soft and nontender with no organomegaly. The remainder of the physical examination shows no abnormalities. Which of the following is the best next step in management of this patient?

Question

A 74-year-old man comes to the office due to difficulty swallowing food.  The symptoms began 4 months ago when the patient was eating steak and felt like a bite got stuck in the middle of his chest, which resolved after drinking a glass of water.  Since then, he has had several similar episodes when eating bread or meat and has modified his diet to soft foods.  He has no difficulty drinking liquids and has had no chest or abdominal pain, vomiting, melena, or weight loss.  The patient has occasional nighttime heartburn, especially after eating spicy food, and takes antacids as needed.  His other medical conditions include hypertension, for which he takes lisinopril.  He does not use tobacco, alcohol, or illicit drugs.  Family history is unremarkable.  Vital signs are within normal limits.  Physical examination shows normal dentition and oropharyngeal mucosa.  Tonsils are normal.  The lungs are clear on auscultation, and heart sounds are normal.  The abdomen is soft and nontender with no organomegaly.  The remainder of the physical examination shows no abnormalities. Which of the following is the best next step in management of this patient?

Quizplus · Accepted Answer

11ec25c8_d8ec_b168_bc81_476b61a4714b_MD0003_00 This patient presents with progressive esophageal dysphagia, characterized by normal initiation of a swallow followed by a sensation that food "sticks" within the esophagus (vs. oropharyngeal dysphagia, characterized by difficulty initiating a swallow and nasopharyngeal regurgitation/aspiration). In an elderly patient with a history of heartburn, this presentation raises the concern for esophageal adenocarcinoma. Adenocarcinoma typically arises in the distal esophagus from Barrett esophagus (a histologic precursor characterized by intestinal metaplasia). Risk factors for esophageal adenocarcinoma include chronic uncontrolled gastroesophageal reflux disease, male sex, older age, and obesity. Early symptoms are subtle and typically begin with solid food dysphagia and may also include retrosternal pain. With time, dysphagia progresses to include liquids; advanced disease results in weight loss, regurgitation, iron deficiency anemia, and occasionally hematemesis. An upper endoscopy is the test of choice to evaluate esophageal dysphagia and exclude malignancy; the procedure allows for direct visualization of a lesion, tissue biopsy, and the performance of interventions (eg, dilation of stricture, stent placement), if needed. (Choice A) A proton pump inhibitor (PPI) trial is appropriate in patients with gastroesophageal reflux disease without red flag symptoms like dysphagia, weight loss, iron deficiency anemia, or persistent vomiting. An upper endoscopy is required if any red flags are present or if reflux fails to improve with PPI. (Choice B) CT scan of the chest is less sensitive than upper endoscopy for esophageal tumors but can be used for staging purposes after a diagnosis is obtained. A barium esophagram is superior to CT in the diagnosis of esophageal cancer; however, endoscopy is still the preferred modality. (Choice C) Esophageal manometry can diagnose dysmotility syndromes like achalasia; however, it cannot rule out cancer. Manometry is indicated if upper endoscopy is unremarkable. (Choice D) Helicobacter pylori testing is indicated for patients with dyspepsia or peptic ulcers, which typically presents with postprandial epigastric pain. However, dysphagia requires further evaluation with endoscopy. Educational objective: Esophageal dysphagia is characterized by a sensation of food "sticking" in the esophagus; in older patients, esophageal malignancy is a common cause. Esophageal malignancy classically presents with progressive solid-food dysphagia; retrosternal pain and weight loss are also common. Upper endoscopy is the test of choice to evaluate dysphagia.

A 74-Year-Old Man Comes to the Office Due to Difficulty